Medical Claims Specialist

23 hours ago

Pasig, National Capital Region, Philippines Connext Full time ₱400,000 - ₱800,000 per year

Job Summary

The Medical Claims Specialist is responsible for the timely submission of technical or professional medical claims to insurance companies. This role involves verifying patient and billing information, editing claims for compliance, resolving denials, and communicating with both payers and internal teams.

Responsibilities


• Utilize various hospital/physician systems to verify patient, billing, and claim information for accuracy.


• Perform compliant primary/secondary, tertiary, and rebill billing functions across electronic, paper, and portal platforms.


• Edit claims to meet payer-specific compliance requirements (electronic and hardcopy).


• Respond timely to email and telephone messages as appropriate.


• Communicate claim issues to management, payers, system contacts, or escalated account owners.


• Participate in department training seminars and in-services to expand job knowledge.


• Serve and protect the hospital community by adhering to policies, procedures, and standards (federal, state, local, JCAHO).


• Support the billing department and hospital reputation by accepting ownership of tasks and delivering value through performance.


• Update patient demographics and insurance details in appropriate systems.


• Monitor claims for missing info, automation flags, or control numbers (ICN/DCN).


• Follow protocols for prioritization, deadlines, and notation accuracy.


• Secure needed documentation from payers or third-party sources.


• Maintain confidentiality of patient information in compliance with policy.

Qualifications and Requirements


• Experience with claims management and rejection editing.


• Familiarity with patient accounting systems such as EPIC, Cerner, STAR, Meditech, CPSI, Invision, PBAR, Allscripts, or Paragon.


• Experience identifying billing errors, correcting and resubmitting claims, and resolving denials or underpayments.


• Familiarity with EOB, UB04, and 1500 billing forms.


• Knowledge of ICD-10, CPT, HCPCS, and NCCI coding.


• Ability to read, interpret, and apply payer contracts.


• Proficient in navigating healthcare information systems (EMR, Patient Accounting, Claim Scrubbers, etc.).


• Understanding of accounts receivable processes and third-party payer coordination.


• Ability to use Internet Explorer, Microsoft Outlook, Excel, and internal email/calendar tools.


• Exhibits a strong ability to work both independently and collaboratively within a team.


• Proven track record of meeting performance metrics and deadlines.


• Clear and coherent in both written and verbal communications skills with the ability to communicate effectively with with payers and team members.

Screening Criteria


• High school diploma or equivalent combination of education and work experience.


• Minimum of two (2) to four (4) years in claims management, claims processing, or claims resolutions, preferably in a hospital or payer setting.


• Must have stable employment history.

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